Risk Associated With Surgery Within 12 Months After Coronary Drug-Eluting Stent Implantation

Egholm, Gro; Kristensen, Steen Dalby; Thim, Troels; Olesen, Kevin Kris Warnakula; Madsen, Morten; Jensen, Svend Eggert; Jensen, Lisette Okkels; Sørensen, Henrik Toft; Bøtker, Hans Erik; Mæng, Michael

doi:10.1016/j.jacc.2016.09.967

Cited by 94 publications

(78 citation statements)

References 23 publications

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“…In the PARIS (Patterns of Nonadherence to Antiplatelet Regimens in Stented Patients) registry, interruption of DAPT based on physician judgment in patients undergoing surgery at any time point after PCI was not associated with a significantly higher risk of MACE nor of stent thrombosis (23). Taking into account these data, the increased safety of new-generation DES, the reduced minimally recommended duration of DAPT after DES implantation and the most recent data about stent and surgery (5,6,18), the latest ACC/AHA guidelines reduced the recommended delay from DES implantation to surgery from >1 year into "optimally at least 6 months", suggesting that even >3 months can be considered in selected cases (15).…”

Section: Management Of Antiplatelet Therapymentioning

confidence: 95%

“…Recent data including more comprehensive identification of surgical procedures, however, changed these figures to around 15-23% within the first year (5,6,10), and up to 40% within 5 years (6). Considering that DES should be preferred over BMS to accomplish coronary revascularization (4), in clinical practice risk stratification must take into account that most of those patients do have a DES in the coronary tree (5).…”

Section: Magnitude Of the Clinical Problemmentioning

confidence: 99%

“…Time from index PCI to surgery is significantly associated with the risk of perioperative cardiac events (5,6,8,18,19). This risk is partially, but not entirely, related to the risk of stent thrombosis.…”

Section: Timing Of Surgery and Cardiac Risk After Stentingmentioning

confidence: 99%

“…Accordingly, previous guidelines provided a general recommendation that elective surgery be delayed until 30 to 45 days after bare metal stent (BMS) implantation and 1 year after DES (3,4). Recently, new evidence has accrued suggesting that the safety window for surgery after implant of new-generation DES could be safely shortened to <6 months (5,6). The aim of this brief commentary is to critically review available data about cardiac risk associated with surgery in patients with coronary drug-eluting stents.…”

mentioning

confidence: 99%

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Surgery after drug-eluting stent implantation: it’s not all doom and gloom!

Saia¹

2017

J. Thorac. Dis.

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Up to 15-23% of the patients with percutaneous coronary intervention (PCI) and drug-eluting stent (DES) implantation need a surgical procedure <12 months from PCI. Perioperative risk stratification in these patients is challenging and should take into account many individual clinical and anatomic variables, along with the intrinsic surgical risk for ischemic and bleeding events. The presence of DES has always been considered as a harbinger of doom. In fact, DES are associated with delayed vascular healing and require longer dual antiplatelet treatment. Perioperative pharmacologic management in those patients is intricate because of the tradeoff between the increased thrombotic risk associated with premature DAPT discontinuation and the increased risk of bleeding in the presence of antithrombotics. Whilst most of the studies agree upon the inverse relationship between time from stenting to surgery and cardiac risk, more recent data challenge the previous belief that surgery should be deferred at least 12 months after DES implantation and this safety window could be shortened to <6 months or even less with new-generation DES. The aim of this brief commentary is to critically review available data about cardiac risk associated with surgery in patients with coronary drug-eluting stents.

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Section: Management Of Antiplatelet Therapymentioning

confidence: 95%

Section: Magnitude Of the Clinical Problemmentioning

confidence: 99%

Section: Timing Of Surgery and Cardiac Risk After Stentingmentioning

confidence: 99%

mentioning

confidence: 99%

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Surgery after drug-eluting stent implantation: it’s not all doom and gloom!

Saia¹

2017

J. Thorac. Dis.

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“…42 The surgical risk compared with that in non-stented patients without CAD was investigated in 22 590 patients undergoing DES-PCI in Western Denmark. 43 Using Danish registries, 4303 DES-PCI-treated patients undergoing a surgical procedure were compared with a control group of patients without previous CAD undergoing similar surgical procedures (N = 20 232 …”

Section: Dual Antiplatelet Therapy and Surgerymentioning

confidence: 99%

The year in cardiology 2017: coronary interventions

Kristensen

Mæng

Capodanno

et al. 2018

European Heart Journal

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PreambleThe first balloon coronary angioplasty was performed in Zurich by Andreas Grüntzig in 1977. The patient, a 38-year-old man with severe angina and a tight stenosis on the left anterior descending artery, is still alive, is doing well, and he celebrated the 40-year anniversary of his percutaneous coronary interventions (PCI) in 2017 ( Figure 1). During the last decades, PCI techniques have undergone major improvements with the first real game changer being the introduction of bare metal stents, which made PCI safer and improved longer-term outcomes. Later on, drug-eluting stents (DESs) were introduced, which resulted in a major reduction in restenosis and also-with the newer generation DES-a low rate of stent thrombosis. Further, the introduction of intracoronary pressure measurements for assessment of severity of coronary stenoses [fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR)] and intracoronary imaging [intravascular ultrasound (IVUS) and optical coherence tomography (OCT)] for lesion assessment has refined lesion and procedure assessment. Improved outcomes were also fostered by development of better and safer adjunctive antithrombotic drugs and secondary prevention, optimizing drug-device synergy. Still, 40 years later the research in the coronary interventional field is very intense, and we aim here to summarize major developments in PCI published in 2017. Myocardial revascularization Percutaneous coronary intervention techniqueThe SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) II study investigated the impact of a contemporary PCI strategy on clinical outcomes of 454 patients with three-vessel disease. 1Characteristics of the SYNTAX II strategy that captures all components of today's 'best of PCI practice' are summarized in Figure 2. Following this approach systematically, the authors demonstrated major adverse cardiac and cerebrovascular events (MACCE) at 1 year to be much improved with respect to a matched historical PCI cohort from the SYNTAX I trial (10.6% vs. 17.4%; P = 0.006). The better result of the contemporary PCI strategy compared with the procedural technique followed at the time of the SYNTAX I trial was driven by a lower risk of myocardial infarction (MI) and revascularization, with a parallel reduction in stent thrombosis. Overall, the SYNTAX II study suggests that the combination of best practice components in PCI technique portends improved patient outcomes beyond what can be achieved by introducing one single new element. Because these results outperform PCI results obtained in the earlier SYNTAX I trial, the hypothesis was generated that a new randomized study of modern best PCI practice in patients with three-vessel disease might show non-inferiority vs. coronary artery bypass grafting (CABG). 1Glimpsing to the future, the feasibility and technical success of robotically-assisted PCI for complex coronary lesions were investigated in 334 procedures from 315 patients included in the Complex Robotically Assisted Percutaneous Coronary Intervention (...

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Perioperative Cardiovascular Risk Assessment and Management for Noncardiac Surgery

Smilowitz

Berger

2020

JAMA

149

140

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IMPORTANCEPerioperative cardiovascular complications occur in 3% of hospitalizations for noncardiac surgery in the US. This review summarizes evidence regarding cardiovascular risk assessment prior to noncardiac surgery.OBSERVATIONS Preoperative cardiovascular risk assessment requires a focused history and physical examination to identify signs and symptoms of ischemic heart disease, heart failure, and severe valvular disease. Risk calculators, such as the Revised Cardiac Risk Index, identify individuals with low risk (<1%) and higher risk (Ն1%) for perioperative major adverse cardiovascular events during the surgical hospital admission or within 30 days of surgery. Cardiovascular testing is rarely indicated in patients at low risk for major adverse cardiovascular events. Stress testing may be considered in patients at higher risk (determined by the inability to climb Ն2 flights of stairs, which is <4 metabolic equivalent tasks) if the results from the testing would change the perioperative medical, anesthesia, or surgical approaches. Routine coronary revascularization does not reduce perioperative risk and should not be performed without specific indications independent of planned surgery. Routine perioperative use of low-dose aspirin (100 mg/d) does not decrease cardiovascular events but does increase surgical bleeding. Statins are associated with fewer postoperative cardiovascular complications and lower mortality (1.8% vs 2.3% without statin use; P < .001) in observational studies, and should be considered preoperatively in patients with atherosclerotic cardiovascular disease undergoing vascular surgery. High-dose β-blockers (eg, 100 mg of metoprolol succinate) administered 2 to 4 hours prior to surgery are associated with a higher risk of stroke (1.0% vs 0.5% without β-blocker use; P = .005) and mortality (3.1% vs 2.3% without β-blocker use; P = .03) and should not be routinely used. There is a greater risk of perioperative myocardial infarction and major adverse cardiovascular events in adults aged 75 years or older (9.5% vs 4.8% for younger adults; P < .001) and in patients with coronary stents (8.9% vs 1.5% for those without stents; P < .001) and these patients warrant careful preoperative consideration.CONCLUSIONS AND RELEVANCE Comprehensive history, physical examination, and assessment of functional capacity during daily life should be performed prior to noncardiac surgery to assess cardiovascular risk. Cardiovascular testing is rarely indicated in patients with a low risk of major adverse cardiovascular events, but may be useful in patients with poor functional capacity (<4 metabolic equivalent tasks) undergoing high-risk surgery if test results would change therapy independent of the planned surgery. Perioperative medical therapy should be prescribed based on patient-specific risk.

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Risk Associated With Surgery Within 12 Months After Coronary Drug-Eluting Stent Implantation

Cited by 94 publications

References 23 publications

Surgery after drug-eluting stent implantation: it’s not all doom and gloom!

Surgery after drug-eluting stent implantation: it’s not all doom and gloom!

The year in cardiology 2017: coronary interventions

Perioperative Cardiovascular Risk Assessment and Management for Noncardiac Surgery

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